Health Systems Impact of

COVID-19 in the Philippines

Diana Beatriz S. Bayani and Soon Guan Tan

Abstract

Lockdowns and policy actions to curtail the transmission of COVID-19 have widespread health
system, economic, and societal impacts. Health systems of low-to-middle-income countries may
have fewer buffering resources and capacity against shocks from a pandemic. This paper presents
a preliminary review on the collateral health systems impact of COVID-19 in the Philippines
through review of academic and grey literature, supplemented by a qualitative survey. Community
quarantines alongside transport and boarder restrictions have universally impacted health service
access and delivery, affecting patients requiring specialist care the most. Existing record-keeping
and surveillance measures were hampered as existing resources were tapped to perform COVID-
19-related tasks. Local health systems reinforced gatekeeping mechanisms for secondary and
tertiary care through referral systems and implemented telemedicine services to reduce face-to-face
consultation. The health system impacts in the Philippines have been variegated across municipal
income class and topography, contributed by long-standing symptoms of inequitable resource
allocation.

JEL: I18

Working Paper 569

March 2021
www.cgdev.org
 Health Systems Impact of COVID-19 in the Philippines

Diana Beatriz S. Bayani and Soon Guan Tan

Saw Swee Hock School of Public Health,
National University of Singapore

Corresponding author: Diana Beatriz S. Bayani,

dbayani@u.nus.edu

This work is part of a multi-country project that is seeking to understand

the nature, scale, and scope of the indirect health effects of the
COVID-19 pandemic. The project is managed by the Center for Global
Development. We are grateful for the inputs of Damian Walker, Carleigh
Krubiner, Y-Ling Chi, Lydia Regan, throughout the conceptualization,
analysis, and synthesis of this work. We also thank Christian Nuevo and
Yot Teerawattananon for their useful comments on earlier drafts.

Contributions to this work were generously supported by Open

Philanthropy and by the International Decision Support Initiative (iDSI).

Diana Beatriz S. Bayani and Soon Guan Tan, 2021. “Health Systems Impact of
COVID-19 in the Philippines.” CGD Working Paper 569. Washington, DC: Center for
Global Development. https://www.cgdev.org/publication/health-systems-impact-covid-
19-philippines.

Center for Global Development The Center for Global Development works to reduce global poverty
2055 L Street NW and improve lives through innovative economic research that drives
Washington, DC 20036 better policy and practice by the world’s top decision makers. Use and
dissemination of this Working Paper is encouraged; however, reproduced
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www.cgdev.org The views expressed in CGD Working Papers are those of the authors and
should not be attributed to the board of directors, funders of the Center
for Global Development, or the authors’ respective organizations.
Contents
Foreword ................................................................................................................................................ 1
Introduction ........................................................................................................................................... 2
Country Profile ...................................................................................................................................... 3
Health Systems Context ....................................................................................................................... 3
Materials and Methods ......................................................................................................................... 5
Conceptual Framework ................................................................................................................ 5
Methods .......................................................................................................................................... 6
Data analysis ................................................................................................................................... 7
Results ..................................................................................................................................................... 7
Overview of COVID-19 Situation & Mitigation Strategies Adopted................................... 7
Health Systems Impact of COVID-19 Mitigation Strategies ............................................... 11
Discussion and Conclusions ............................................................................................................. 16
References ............................................................................................................................................ 18
Foreword
On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic.
With dire predictions about how the virus could devastate populations and overwhelm
health systems, many countries imposed stringent measures to limit spread and the resulting
morbidity and mortality. Yet most of these policy approaches focused narrowly on potential
impacts for COVID-19, without sufficient attention to how the pandemic and various
response measures would have broader indirect impacts across other health needs and health
services. While the evidence of disruptions to essential health services was largely anecdotal
to begin with, and its health effects mostly modeled, increasingly detailed evidence is
beginning to emerge from countries.

Over the past year we partnered with research institutions in Kenya, the Philippines, South
Africa, and Uganda to document, from a whole-of-health perspective, what we know about
the nature, scale, and scope of the disruptions to essential health services in those countries,
and the health effects of such disruptions. This research provides initial insights on the
observed near-term indirect health impacts of the pandemic and response measures, relying
on the best available data in the months following lockdown measures. However, it is
important to recognize the limitations of conducting research during a pandemic and a
continuously evolving epidemiological and policy context. We plan to build on these studies
as more and better data become available, and as public health responses continue until the
pandemic is brought under control.

In this paper, Diana Beatriz S. Bayani and Soon Guan Tan present findings on the collateral
health system impacts of COVID-19 and its mitigation strategies in the Philippines. They
show us that the story is nuanced; disruptions vary by service, by geography, and by sub-
populations. They also remind us that evidence of disruptions today is a leading indicator of
health effects in the future.

We are hopeful that the findings from this working paper – and the project as a whole – will
contribute to our global knowledge about the ongoing and lingering effects of the pandemic,
and ways to mitigate these effects. It is not too late for action. Armed with the kind of
evidence in this working paper, national governments and global partners must focus their
efforts on the most affected, most cost-effective services, and ensure that any lost
generations due to the pandemic are minimized.

Carleigh Krubiner
Policy Fellow
Center for Global Development
Damian Walker
Non-Resident Fellow
Center for Global Development

1
Introduction
Governments across the globe are increasingly reliant on outputs of disease modelling to
assess the risk of a pandemic and the cost-benefit of action (or inaction) to mitigate novel
health threats. The use of models to inform suitable policy response was particularly evident
in light of response against the COVID-19 pandemic (1–4). However, to date, models have
had a near singular focus on COVID-19 cases and deaths and have not accounted for the
vastly different contexts of countries, including the trade-offs and economic shocks that
greatly affect how mitigation strategies translate to lives saved, especially in low- and middle-
income countries (LMICs) (5).

Most existing models were not designed to contextualise impacts on the wider health care
system and so, do not capture indirect health effects of policies; the knock-on or collateral
health effects. This omission is not without consequences. Past pandemics and outbreaks
have produced substantial evidence on the indirect health impact such as secondary
mortality arising from policy interventions (6). During the 2014-2015 Ebola crisis in West
Africa, it was estimated that a 50 per cent reduction in access to services led to an additional
10,600 deaths just from malaria, HIV/AIDS and TB—almost equal to the 11,300 deaths
directly caused by Ebola (7).

Nearly a year into the pandemic, there has been substantial evidence and reports detailing
the indirect health impacts of lockdowns and travel restrictions (8–11). Beyond impacts in
the health systems alone, it is clear that repercussions of policy actions can ripple into the
social, behavioural, economic and environmental domains in society that translate to health
outcomes immediately and in the long run. LMICs in particular, may be disproportionately
impacted due to the fragility of health systems with limited capacity and resources to buffer
against shocks (12).

There is a need to understand the indirect effects of not just the pandemic itself, but also
unintended effects of mitigation measures that have been adopted to contain it. This
knowledge can allow for context-specific, tailored mitigation and suppression strategies to be
considered, with the dual goals of controlling the epidemic and averting the worst direct and
indirect health impacts.

At present, much of the literature and focus has been on the effect of mitigation measures
on COVID-19 cases, deaths, testing capacity and other COVID-19 related-metrics.
However, there have been limited attempts to understand how these pandemic mitigation
measures, applied within the context of an LMIC, can impact different aspects of the health
systems and thus, the population health. Thus, this paper aims to present a preliminary
review of the collateral health systems impact of COVID-19 and its mitigation strategies in
the Philippines.

2
Country Profile
The Republic of the Philippines is an archipelago in Southeast Asia geographically divided
into three island groups: Luzon, Visayas and Mindanao (13). It is subdivided into 17
administrative regions consisting of 81 provinces, 146 cities, 1,488 municipalities for
economic development and coordination of national government services (14).

The Philippines is a relatively young and populous country. In 2018, the population of the
Philippines is estimated to be at 105.7 million with 49.7 percent of the population is below
the age of 25 and 5.2 percent of the population is aged 65 and above (15). Poverty incidence
stands at 16.7 percent and subsistence incidence was 5.2 percent in 2018 (16). Over half
(51.2 percent) of all the population is residing in urban areas (17). The observed life
expectancy in 2017 is at 73.1 years for females and 66.6 years for males. Under-5 and Under-
1 mortality rate is at 26.6 and 19.9 per 1,000 live births respective in 2017 (18).

Health Systems Context

The Philippine health system is highly decentralised and devolved, with a mix of tax-
financed public sector and for-profit and non-profit private sector providers. The
Department of Health (DOH) is the lead agency involved in leadership, governance and
regulation in health and provision of special tertiary health care services (19). Governance of
localities, alongside health services delivery, social welfare services and maintenance of
municipality facilities have been largely decentralised to local government units (LGUs) by
the Local Government Code of 1991 (19,20). The aim of the devolution was to achieve a
responsive and efficient delivery of basic primary health care and hospital care by shifting
stewardship and overall decision-making to the LGU level (20).

The Philippines has made significant strides in advancing universal health coverage (UHC)
through the Universal Health Care Act (Republic Act No. 11223), which was signed into law
on 20 Feb 2019 (21). Under the Act, all Filipinos are automatically enrolled into the National
Health Insurance Program (NHIP), a social health insurance scheme managed by the
Philippine Health Insurance Corporation (PhilHealth). Alongside major health systems
reform and delineation of roles across key agencies and stakeholders, this act aims to ensure
that all Filipinos are able to gain equitable access to quality and affordable health care (21).

Despite significant reform in devolving health services and advancing UHC, this progress
has not been uniformed. Several longstanding challenges such as highly fragmented care,
maldistribution of health facilities, health human resources and financing continues to afflict
the Philippine health system (20,22,23). Notably, widespread inequity persist in health
services access and health outcomes across geography and socioeconomic strata (20,24–26).

Several macro indicators highlight the extent of inequity in the system. Health facilities
resources and workforce remains variable across geographic regions. National data reflect an
average of 10.1 hospital bed per 10,000 people in the Philippines in 2015, however,
disaggregated data indicate that resources are concentrated in urbanised regions, mostly in
the National Capital Region (NCR). (19). In the same vein, healthcare workforce distribution

3
in the Philippines is also highly inequitable. In 2017, there are 3.9 doctors for 10,000 people
nationally, but disaggregate statistics reveal that the density ranged from 10.6 per 10,000 in
the NCR to 3.1 and 0.9 in Western Visayas (Region VI) and Autonomous Region in Muslim
Mindanao respectively (19).

Against the backdrop of these health reforms and challenges, the Philippines is facing a triple
burden of disease of communicable disease (CD), non-communicable diseases (NCDs) and
natural disasters (typhoons, floods, earthquakes) (22,27). The leading cause of death,
disability and the underlying risk factors are presented in Figure 1. In sum, the deficiencies in
the health systems discussed above, coupled with the triple burden of disease poses a
fundamental challenge in priority setting, not only in terms of financing healthcare but also
in the delivery of services and implementation of programmes. This proves to be even more
difficult in a crisis of a large scale such as the COVID-19 pandemic, where existing inequities
were further exposed and exacerbated by many of these perennial weaknesses.

Figure 1. Top 10 causes of death, disability (years lived with disability) and risk
factors contributing to most the most death and disability (Disability Adjusted Life
Years (DALYs)) combined in the Philippines, 2017, all ages number

Source: Institute for Health Metrics and Evaluation (18).

Note: COPD, Chronic obstructive pulmonary disease; LDL, Low-density lipoprotein.

4
Materials and Methods

Conceptual Framework
We applied a conceptual framework (Figure 2) developed from previous review work (28).
The framework examines the indirect short to long term impacts of pandemic mitigation
measures on health systems if left unmitigated. The purpose of this framework is to help
identify broad areas of health and health care that may be affected by disruptions in
provision and access to healthcare services from the health systems perspective. Indirect
effects can range from health outcomes such as morbidity and mortality, service delivery
outputs such as an expected change in utilization and access. By the same token, it can be
used to support the design of strategies to mitigate indirect health impacts from health
system disruptions.

Figure 2: Framework to Assess Health Systems Impact

5
The present study adopted the framework to identify the collateral health system impact of
COVID-19 in the Philippines. This includes a review of academic and grey literature and
qualitative inquiry with key informants in the Philippine health system.

Methods
First, a review of existing literature, both from academic and non-academic (i.e. grey
literature) was conducted. Grey literature, including news reports, publications from non-
governmental organisations, official government reports and websites were identified and
considered. The conceptual framework in Figure 2 was used to guide the literature search
process. Under each sub-factor of why services are affected (e.g. health workforce, service
provision, patient access), we started by scoping out the extent of the short-term impacts of
COVID-19 measures. The sub-points under the short-term impacts (for instance,
“affected”, “impact”) were used as search terms and keywords to guide literature review.

A qualitative study was conducted through in-depth interviews with health system managers
in different levels of care in the Philippines. The primary purpose of the interviews was to
complement findings obtained from literature and understand experiences on the ground
that may not have been reported in secondary data sources. The qualitative approach
allowed for the gathering of information, experiences and challenges faced by the
interviewees (29). In addition, the unique flexibility of the KIIs allowed participants to
present rich data offering embodied perspectives and the interviewers to probe to detailed
accounts of their experiences.

Participants were recruited through purposive and snowball sampling. There were two main
categories of respondents: 1) Local health system managers such as the Municipal Health
Officer (MHO) and Rural Health Physicians (RHP) who both work at the local government
unit (LGU), 2) Medical centre chief or head of hospital to provide expert input and insights
on the impact of policy actions on the ground. We recruited participants to cover at least all
three island regions in the Philippines to gain a brief understanding of the situation on the
ground. We also ensured that we got a variety of respondents across municipal income
classes (1st to 6th class), and topography (island, landlocked and mountainous). We also
interviewed one department head in a teaching hospital that was a designated COVID-19
facility to understand the effects at the tertiary level.

We conducted semi-structured interviews of participants via telephone or video calls from

12 September 2020 to 7 October 2020. The interview guide was constructed based on the
health systems impact framework in Figure 2. All interviews were audio-recorded, with the
acknowledgement and verbal consent of the interviewees before the interview. They were
first asked to describe their municipality or hospital in terms of demographics, patient
volume, common causes of morbidity and mortality and service delivery network before the
pandemic to understand the local context better. After which, we validated whether their
area followed suit with national community quarantine guidelines, and asked about different
measures that were implemented as a response. After having a good understanding of the
baseline pre-pandemic scenario, participants were then asked to describe observed changes
in service disruptions, as well as behaviour, access to care and health outcomes of their

6
catchment population. They were also asked about their opinion and views on the
appropriateness of lockdown measures implemented, how they adapted to these and key
challenges they faced. All interviews were conducted by the lead researcher (DB) together
with a scribe (TSG) and were done in English.

This study was reviewed and granted exemption by the Single Joint Ethics Review Board of
the Philippine Department of Health (SJREB-2020-62).

Data analysis
Relevant data obtained through the literature review were first collated and organised in the
relevant subsections. Anecdotal data and quantitative estimates (where available) of findings
indicating the downstream impact of COVID-19 lockdown measures were collated and
mapped to the framework.

Audio-records of the interviews were transcribed and analysed using thematic analysis to
identify, analyse and report patterns within the data (30). The analysis of the interviews was
done concurrently with the literature review and recruitment of participants to identify
emergent themes from literature reviews and estimates for indirect health benefits
calculation. Themes and quotes reported in the case study were anonymised, removing
potential identifiers (e.g. roles/titles, location of practice).

Results

Overview of COVID-19 Situation & Mitigation Strategies Adopted

Government response to the COVID-19 pandemic

The Philippines has adopted a whole-of-government and whole-of-society approach to
combat COVID-19. The Inter-Agency Task Force on Emerging Infectious Diseases (IATF-
EID) (31), chaired by the Department of Health (DOH), with representatives from various
other government departments, was convened in early January 2020 and directed much of
the response and mitigation measures against the COVID-19 pandemic (32).

Bayanihan to Heal As One Act (Bayanihan Act) and Bayanihan to Recover as One Act
(Bayanihan 2) were two consecutive legislations passed by congress granting the President
additional authority and also to expedite the implementation of measures to address the
collateral impact of the COVID-19 pandemic (33). Amongst the plethora of policies
measures, the act allowed the reallocation of budget for fiscal stimulus, social amelioration
programmes through cash aids for low-income households, hazard compensation for
frontline health workers and laws against hoarding, profiteering during the pandemic (33,34).

7
The Philippines government has relied on non-pharmaceutical interventions (NPIs), like
many other countries, to contain COVID-19 transmissions. In the initial phase of the
outbreak, selective measures involving quarantine of returning travellers and travel
restrictions to and from high-risk regions were imposed. These NPIs progressively included
more stringent and broad-based interventions, involving community quarantines (31).

Lockdowns, termed ‘community quarantines', have been Philippines’ key strategy to limit
COVID-19 spread. These quarantine measures are classified into four varying levels of
stringency summarized in Table 1. The enhanced community quarantine, termed ECQ, is
the highest level of quarantine measures imposed in areas with high transmission risk.
Population mobility is severely restricted under ECQ as the entire population were placed on
stay home orders, with suspension of public transportation and non-essential services and
businesses (35). Mass gathering and movement across states and borders are prohibited
unless for essential purposes, defined as those related to the provision of food, water,
medicines, medical devices, public utilities, energy and others determined by the IATF.

Modified ECQ (MECQ) is reserved for high to intermediate risk areas, with some work and
activities allowed to resume under strict guidelines. General Community Quarantine (GCQ)
is implemented in areas of low to intermediate transmission risk. Modified GCQ (MGCQ) is
the lowest level of community quarantine, with further socio-economic activities permitted
with adherence to public health protocols and gatherings of up to ten persons. Under all
levels, the public are to adhere to IATF-EID’s minimum public health guidelines for
COVID-19. This includes donning facemasks, observing hand hygiene and personal hygiene,
frequent sanitation and complying with physical distancing guidelines in public spaces (36).

Community Quarantine Measures

ECQ was imposed in Metro Manila from 15 March to 15 April 2020 and was subsequently
extended to the rest of Luzon Island two days later as local transmission of COVID-19 cases
continually increased. The ECQ was later extended to 30 April as recommended by the
IATF-EID. From 1 May to 31 May 2020, only select areas in Luzon were under ECQ or
MECQ based on COVID-19 risk assessment (37).

The COVID-19 Government Response Stringency Index (Stringency Index) by Oxford

COVID-19 Government Response Tracker (OxCGRT) is a composite measure that informs
stringency of government policies and response (38). From the point of ECQ to April, the
stringency index was at its maximum score of 100. However, the number of new cases of
COVID-19 did not drastically decline but increased, even towards the end of May. As of 1
October 2020, there are 311,694 confirmed cases of COVID-19, with 50,925 active cases
and 5,504 COVID-19 deaths. National Capital Region (NCR), Batangas, Bacolod City, Iloilo
City, Tacloban City, Iligan City, and Lanao del Sur remained in GCQ status while the rest of
the country was under MGCQ (39). Figure 3 shows the cumulative and daily confirmed
cases and deaths from COVID-19 vis-à-vis the OcCGRT Stringency Index.

8
 Table 1. Summary of key community quarantine measures across different stringency
levels adopted in the Philippines

Enhanced Modified Enhanced General Modified

Community Community Community General Community
Quarantine Quarantine Quarantine Quarantine
(ECQ) (MECQ) (GCQ) (MGCQ)
High-risk Moderate to For moderate to Proposed for
areas high-risk areas low-risk areas low-risk areas
MOVEMENT AND GATHERING
Population All are expected to stay at home. Population at high-risk (vulnerable elderly
and youths) required to stay home
Mass Gathering Not allowed Highly Restricted Restricted Allowed, limited to 50
(5 maximum) (10 maximum) percent of the venue
capacity
Transportation Public transportation is not allowed Public transport is allowed with strict
physical distancing guidelines and safety
protocol
Inter-island No inter-island travel Inter-island travel (GCQ to GCQ) allowed
Travel with safety protocols
SCH OOLS, WORKPLACES AND GOVERNMENT SERVICES
Businesses and Work suspensions, Essential industries Essential industries Full operating capacity
Workplace exception for permitted to work at permitted to work for public and private
Arrangement workers in offices full capacity, with at full capacity, offices. Alternative
or industries others operating at a with others work arrangements for
permitted to 50% capacity operating at 75% elderly persons or
operate capacity those with other health
risks
Businesses
providing basic
necessities are
allowed to operate
Government Skeletal workforce Skeletal workforce Alternative work Physical reporting for
Services arrangement work with safety
guidelines
Schools School premises School premises closed Skeletal workforce Limited face-to-face or
closed permitted in in-person classes may
schools be conducted
Sources: Official Gazette of the Republic of the Philippines. Executive Order No. 112, s. 2020 (35); Official Gazette of the Republic of
the Philippines. Omnibus Guidelines on the Implementation of Community Quarantine in the Philippines with Amendments as of
July 16, 2020 (36)

9
 The decision to impose, extend or lift a community quarantine in provinces, highly
urbanised cities and independent component cities were determined by the IATF and Office
of the President. Regional IATFs and their respective LGUs can decide for their component
municipalities within their provinces, but the degree of stringency cannot be lower than what
was recommended at the provincial level (35). LGUs are not to declare their own
community quarantine measure without concurrence with their respective regional IATFs.
As a result, across different localities and regions, the level of stringency may greatly differ.

Figure 3: Cumulative and daily confirmed cases and deaths from COVID-19 with Oxford COVID-19
Government Response Tracker (OxCGRT) 'COVID-19 Government Response Stringency Index
(Stringency Index) from 13 January 2020 to 30 September 2020.

Source: COVID-19 cases and death counts are obtained from:

https://ourworldindata.org/coronavirus/country/philippines?country=~PHL. Stringency index data is obtained
from: https://ourworldindata.org/policy-responses-covid (40).
Note: The shaded area of the graph represents the main community quarantine measure imposed in the Philippine
in descending order of stringency, with the darkest shade of blue presenting ECQ; followed by MECQ and the
lightest representing GCQ & MCQ.

10
 Health Systems Impact of COVID-19 Mitigation Strategies

Effects on patient access and health service delivery

Transport and border restrictions introduced by community quarantine measures have
universally impacted health services access and delivery. Rapid surveys conducted by various
agencies reflected reduced access to basic services and health facilities in the earlier phase of
the pandemic (Table 2). Care seeking behaviours in both providers and patients have also
changed as a result of NPIs and the fear of contracting COVID-19. On the supply side, the
measures to contain COVID-19 have siphoned away significant manpower and resources
that provide routine essential services.

Table 2. Impact to access to healthcare services in various reports

Organization/ Survey Sample

Agency Region Period Size Related Findings
UN Women Rapid Not stated 23 April 1,883 Seeking medical care and supplies
Assessment Survey (41) 2020 • 66 percent of women and 75 percent
of men indicated that they were
unable to seek medical care when
needed
• 69 percent of women and 81 percent
of men indicated difficulty accessing
medical supplies/hygiene
products/food
National Economic and All regions, 5 April 389,859 Accessing health facilities
Development Authority 47.6 percent to 8 April • 38.5 percent of respondents indicated
(NEDA) (42) from NCR 2020 that they encountered difficulty in
accessing health facilities
• 49.1 percent encountered difficulty in
accessing pharmacies
World Vision Philippines 42 16 May to 985 Accessibility of health services
(43) municipalities 6 June 2020 compared to before COVID-19
and 6 cities in Pandemic
20 provinces • Essential health service: 26 percent
decline
• Maternal centres: 13 percent decline
• Mobile health clinic: 12 percent
decline
Only 25 percent of the household
survey respondents are able to meet
health care and medical expenses of
household members, including children

11
Respondents from the qualitative interviews unanimously agreed that patients requiring
specialist care, both emergent and non-emergent, were impacted the most by community
quarantine measures. Specifically, these are the patients with complicated or high-risk
pregnancies, stroke, and myocardial infarction. Many of these emergent cases were cited to
die in transit as they were either not brought to the appropriate secondary and tertiary
facilities due to travel restrictions, or rejected by emergency departments of the nearby
hospital as they were only accepting COVID-19 patients. The extent of this disruption
varied greatly, although this was more evident in the geographically isolated municipalities
(i.e. mountainous or island) where the nearest facility requires both land and sea transport.
Community quarantine protocols required special passes for these patients to be transported,
which cannot be immediately given for those needing emergent care. Non-emergent cases
needing specialist care (e.g. peritoneal dialysis, diabetes patients) faced challenges in getting
the necessary approvals as they were not considered as having life-threatening illnesses.
Demand-side factors also played a role in the reduced access to speciality services.
Respondents shared that the majority of patients were discouraged from seeking hospital
care due to fear of getting COVID-19, in addition to the tedious process of obtaining
approvals for travel.

In contrast, when asked about the interruption to routine primary care services, these were
described as “minimal”, as the rural physicians found ways to adapt to the restrictions.
Possible inconsistencies from the results from the cross-sectional surveys (Table 2) may be
attributed to the surveys not delineating the level of care (primary or specialist care in tertiary
centres), and most were conducted in the NCR, comprising of high-urbanized cities where
the extent of disruption may be drastically different. Interviewees also cited that many
municipalities implemented telemedicine either through a dedicated hotline for phone or
radio-based consultations. Other channels such as social media were also tapped to
disseminate information about their community’s COVID-19 situation. Barangay Health
Workers (BHW) and Public Health Nurses played a more active role in the local health
system; they delivered prescription medicines and family planning commodities to patients’
homes, scheduled vaccination visits, and did-prenatal check-ups at the barangay level. One
participant cited that this even improved the implementation of the referral system as they
would contact the BHW first, whose concerns were brought up to the assigned nurse before
it was raised to the MHO.

The extent and impact of disruptions varied largely depending on access to care at baseline
(pre-COVID-19), municipal income class, topography and severity of COVID-19. Poorer
municipalities and those with indigenous populations were mentioned to be
disproportionately affected. One respondent from a municipality in Mindanao added that
margin for impact was already poor to pre-COVID and most patients, particularly those in
remote barangays, were most affected.

“… patient access to healthcare was already very poor even before ECQ…
the indigenous peoples have more difficulty accessing care since their needs
have never been met even before COVID-19, so they were already at a
bigger disadvantage.” – 004-RHP from Mindanao

12
Effects on health information systems and human resources
The impact of COVID-19 on health information systems activities, including record-
keeping, data collection and surveillance, were found to be mixed. In areas operating with a
lean health care team, task-shifting were noted to be common, with staff performing
additional duties related to COVID-19 on top of their usual role.

“For example, for me as a MHO, there was a time I had to do the

swabbing, I had to do sample preparation. So, I was functioning as a med-
tech (medical technician). There was a time where my midwife was acting as
a nurse, to make (provide) direct care for the patient, there was a time
where my administrative aide, which is a non-clinical or non-healthcare
person, (we) had to delegate some tasks, medical tasks to those persons. So,
a lot of task shifting was done to accommodate changes due to COVID…”
– 001-MHO from Luzon

The expansion of roles contributed to significant delays in reporting of indicators and

balanced scorecard to the Department of Health. Another informant shared that vital
statistics data that needed validation of paper records were delayed due to the movement
restrictions from one island to another.

Conversely, the first-class municipality shared that most of their regular operations pushed
through without significant disruptions, except for special projects such as medical missions
and research activities. The physician from a first-class municipality in Luzon even shared
that they were able to hire additional staff such as contact tracers and encoders so that data
recording and reporting were not impeded.

Changes to service delivery networks

The service delivery networks of health systems have been widely impacted by the shifts in
behavioural patterns of both patients and providers. At the patient level, barriers to access
onsite care due to border and transportation restrictions and the fear of contracting
COVID-19 drastically reduced patient volumes at health centres, particularly at higher level
care facilities. At provider level, interviewees shared that they adapted by implementing
programs and innovations in health care delivery while still adhering to the quarantine
protocols. The most common change cited was the reinforcement of the referral system to
avoid unnecessary visits to the health unit. This approach leveraged the existing community
health care staff by designating specific roles at the barangay level. Complementing the
reinforced referral systems, Barangay Health Emergency Response Teams (BHERTs),
composed of a barangay (community) executive officer, tanod (guard) and health workers,
were mobilised by the government to support community efforts against COVID-19 (44,45).
BHERTs tasked to provide surveillance, monitor home quarantines, contact tracing and
support COVID-related healthcare needs to minimise disruptions to care during the
pandemic and lockdown measures.

13
An interesting observation was that some municipalities saw a reversal in outpatient volume
and deliveries at the rural health unit once COVID-19 cases were stabilized. These facilities
faced increased case load compared to their usual, pre-COVID levels as patients preferred
accessing care in a smaller facility rather than go to a hospital. Alluding to this observation at
the primary/rural care setting, the chief of a tertiary care facility highlighted that patient
volumes, which was contributed by largely by primary care outpatients consults pre-COVID,
may not return back to baseline as patients begun to seek care at the right levels.

“… our most common outpatient consults unfortunately, though we are a

tertiary care center, it's still hypertension, presbyopia and diabetes. So, it's
still a primary care outpatient mostly…”– 006-Chief of Tertiary Care
Facility

“I think now the challenge is how to bring back all those patients…. which,
of course, not all of them, the ones that we can truly serve. And we realize
that maybe we will not have as many as we did before, because everyone
came here, the big hospital mentality, they have a cough, they wanted to
come to (our hospital) in cases it’s pneumonia, right, or a UTI just in case
it's a something more severe. Maybe people realize they can go to other
(lower tier and level) hospitals, because that's what they're doing now.”–
006-Chief of Tertiary Care Facility

This emphasizes the need for a more organized service delivery network, which is one
component of the Universal Health Care Law that has been put on hold since the start of
the pandemic. There is no formal gatekeeping mechanism in the existing system; patients are
free to seek care in secondary and tertiary facilities without a referral from a primary care
physician. However, given the restrictions brought about by COVID-19, strengthening
primary care and community-oriented practices becomes an imminent priority.

Excess Mortality
During the imposition of ECQ measures in the Philippines, there was a reduction in the
number of deaths registered in March and April, accompanied by a gradual return to baseline
and a slight increase in July when compared to 2015 to 2019 average (Figure 4) (46). Daily
average deaths registered in March and April 2020 declined by 100 deaths as compared to
2015-2019 average. This increase in number of late registered deaths as compared to 2019,
corroborated with accounts from rural health physicians that were interviewed for the study
that collection and reporting of vital statistics were delayed. This reduction reverted to
normal in May and an increase in mortality in June and July 2020 as compared to averages in
the preceding five years. Registered deaths in August 2020 was substantially lower, although
the preliminary report from the Philippine Statistics Authority cautioned that more late
registrations may be account for later (46).

14
 Figure 4. Registered deaths in the Philippines from January to August 2020,
as of 30 September 2020

Positive impact of mitigation measures

The impacts of lockdown measures on the environmental aspect of health have been largely
positive in several countries (9,47). While access to health services have been dampened by
lockdown measures, it has also brought about positive impacts that led to reduction in
mortality and morbidity from traffic accidents and plausibly air pollution. Death attributed to
land transport accidents accounts for 12,487 (~1%) of all deaths recorded in the Philippines
in 2018 (15). Reduction in traffic-related deaths and injuries due to restricted mobility and
travel was observed in the Metro Manila during the imposition of ECQ. Road crash statistics
from Metro Manila indicate 80 percent reduction in cases of fatalities in April 2020 under
ECQ, compared to 2018 and 2019 average. Non-fatal injuries saw a larger reduction of over
80 percent from April to June 2020 (48–50). The absence of routinely published statistics on
traffic accidents from other regions, limits our assessment of traffic mortality from other
regions of the Philippines with varying population densities and traffic.

Related to traffic volume, air quality in the Philippines have also improved from the
quarantine measures (51,52), as observed in other countries that instituted lockdown
measures as well (9,53,54). In Metro Manila, tropospheric nitrogen dioxide (NO2) dropped
by approximately 52 percent in comparison to 2019 levels under ECQ and particulate matter
2.5 (PM2.5) levels decreased by 180 percent ten days following the start of the ECQ (52).
Modelling estimates examining from China and Europe suggest that improved air quality
from quarantines may contribute to reduction in deaths from cardiovascular and respiratory
diseases (55). While this observation may be plausible, we were unable to identify empirical
evidence detailing mortality or morbidity reduction attributed to air quality improvements
during the pandemic from the Philippines.

15
Discussion and Conclusions
This paper presents an attempt to understand the collateral impact of COVID-19 and
quarantine measures in the Philippines through a review on academic and grey literature,
supplemented by a qualitative survey. The findings presented in this study highlights that the
immediate and longer-term health impacts brought by quarantine measures are intricately
connected and needs to be considered in pandemic response measures. Estimating the
collateral impact of COVID-19 and NPIs across major disease burdens groups is an
incredibly complex endeavour. The heterogeneity across and within localities in
sociodemographic factors, population density, LGU’s decision to impose CQs, as well as a
constellation of other factors adds on a layer of complexity in estimating indirect impacts of
COVID-19.

Beyond the economic aspects of a lockdown, it is evident that imposing a lockdown brings
along a heavy societal cost that is entangled with immediate and long-term health outcomes.
Discussions on imposing lockdown have often been weighed by the trade-offs between the
public health (anchoring on COVID-19 cases and death) and economic dimension.
However, this trade-off should not be viewed as a dichotomous one. Community quarantine
measures should not be seen as an intervention that imposes a set of restrictions inflexibly.
There should be responsive surveillance systems in place to monitor the effects and provide
timely feedback to policy makers. Clearly, flattening the epidemic curve goes hand in hand
with social protection measures and other policies directly responding to the needs of the
population.

We had a strong interest in reporting all health impacts in terms of mortality as it is the most
objective measure and allows for better comparability with other settings. Excess mortality
data has been used to estimate the direct and indirect mortality attributed to COVID-19 (56).
Excess mortality is defined as the difference in the number of deaths arising from death
from all causes compared with the expected deaths in a specific time period, usually with
reference with mortality data in the previous years. Reports examining excess mortality have
helped elucidate the age groups and geographic regions that have been disproportionately
impacted by COVID-19 (10).

In our analysis of death statistics, we were unable to attribute any particular cause in the
reduction of registered deaths identified in March and April 2020. Unlike most countries
which experienced excess mortality (not due to COVID-19) from factors such as health
systems overload, the reduction in registered deaths in the Philippines was rather peculiar.
On closer inspection, there was an increase in deaths in the National Capital Region and
CALABARZON region (46). It is unlikely this reduction is due to surveillance bias and there
will be additional late registered deaths. Factors that have led to this reduction could be due
to the reduction in traffic-related accidents, mortality from metabolic respiratory and
cardiovascular NCDs commonly aggravated by air pollution (55), and unhealthy lifestyle and
behaviour. These early figures must be interpreted with caution, given that there is still a lag
in reporting and may further contribute to additional deaths in the more recent months.

16
It is likely that the findings observed in the first six months since the start of the COVID-19
pandemic are just the tip of the iceberg. Health effects in the medium and long-term must be
continuously monitored and evaluated, and learnings from this exercise can be used to
mitigate the longer-term effects. Our findings are mainly hypothesis generating and require
further testing and validation through an in-depth analysis of actual, more granular data on
mortality and health service delivery when they become available. A larger study involving a
nationally representative sample of hospitals and municipalities is warranted. Another
limitation is that reports and studies presented in this review come from a wide range of
sources, both published and grey literature where quality is also varied.

While it is without a doubt that the COVID-19 pandemic brought about severe negative
impact to the country, it cannot be denied that there were lessons and realizations that could
be leveraged to bring about positive impact for the future. Key findings on the need for
coordinated service delivery networks were emphasized, and must be prioritized together
with other reforms stipulated in the universal health care program. However, it must be
noted that strengthening the health system requires more than just the cooperation of health
care facilities and health professionals. Good health governance and a whole-of-health
approach is also needed to improve the local health systems to be more resilient, adaptive,
and responsive to the needs of the people.

17
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